Creating Naptime: An Overnight, Nonpharmacologic Intensive Care Unit Sleep Promotion Protocol

Abstract

Introduction: Patients in the intensive care unit (ICU) have significantly disrupted sleep. Sleep disruption is believed to contribute to ICU delirium, and ICU delirium is associated with increased mortality. Experts recommend sleep promotion as a means of preventing or shortening the duration of delirium. ICU Sleep promotion protocols are highly complex and difficult to implement. Our objective is to describe the development, pilot implementation, and revision of a medical ICU sleep promotion protocol.

Methods: Naptime is a clustered-care intervention that provides a rest period between 00:00 and 04:00. We used literature review, medical chart review, and stakeholder interviews to identify sources of overnight patient disturbance. With stakeholder input, we developed an initial protocol that we piloted on a small scale. Then, using protocol monitoring and stakeholder feedback, we revised Naptime and adapted it for unitwide implementation.

Results: We identified sound, patient care, and patient anxiety as important sources of overnight disturbance. The pilot protocol altered the timing of routine care with a focus on medications and laboratory draws. During the pilot, there were frequent protocol violations for laboratory draws and for urgent care. Stakeholder feedback supported revision of the protocol with a focus on providing 60- to 120-minute rest periods interrupted by brief clusters of care between 00:00 and 04:00.

Discussion: Four-hour blocks of rest may not be possible for all medical ICU patients, but interruptions can be minimized to a significant degree. Involvement of all stakeholders and frequent protocol reevaluation are needed for successful adoption of an overnight rest period.

Keywords: circadian rhythm; clustered care; delirium; intensive care unit; sleep.

Figure 1.

Model of intensive care unit sleep disruption based on Spielman’s 3P model of sleep disruption (insomnia). Many of the listed precipitating factors are modifiable in the intensive care unit setting.

Figure 2.

A, Medical intensive care unit floor plan. Cross-hatched rectangles around the perimeter are patient rooms. Unlabeled gray areas are offices or closed supply closets. Open (white) and closed (gray) work areas, a closed conference room, stairs, and unit doors are located as indicated. B, Patient room floor plan. Standard furniture and common clinical equipment are located as indicated. The door is sliding glass. Interior windows allow monitoring from hallway computer desk. There is a large exterior window in every patient room.